Choosing Wisely is an initiative by the ABIM Foundation to identify commonly-used tests or procedures whose necessity should be questioned and discussed. This information was developed by Consumer Reports in cooperation with the American Gastroenterological Association Institute.

If you have heartburn, or a feeling of burning pain in your upper abdomen or lower chest, you might be tempted to try a powerful drug such as Nexium, Prevacid, or Prilosec. Those drugs, called proton pump inhibitors (PPIs), can be good choices for severe or frequent heartburn. But in most cases PPIs aren’t necessary. And when they are, consider using the lowest dose necessary for as short a time as possible. Here’s why.

You might not need a PPI

A PPI can help if you have heartburn more than twice a week for several weeks, or a condition called gastroesophageal reflux disease (GERD). But studies suggest that up to 70 percent of people taking a PPI were never diagnosed with GERD. Instead, they might have less serious heartburn, which can often be eased with dietary and other lifestyle changes and, if necessary, antacids like Rolaids and Tums or another class of medication, known as H2 blockers, such as Pepcid AC and Zantac.

The drugs can pose risks

High doses of PPIs, and taking them for a year or longer, has been linked to an increased risk of bone fractures. Long-term use might also deplete magnesium blood levels, which, in turn, can trigger muscle spasms, irregular heartbeats, and convulsions. Another complication of long-term use is an intestinal infection called Clostridium difficile that can lead to severe diarrhea, fever and, in rare cases, death. PPIs can also interact with other medications. For example, omeprazole (Prilosec) can reduce the blood-thinning effect of the drug clopidogrel (Plavix), which can increase the risk of heart attack and even death. Esomeprazole (Nex- ium), and the H2 blocker, cimetidine (Tagamet), might also interact with Plavix in that same way.

PPIs cost more

A month’s supply of a prescription strength PPI could cost you about $100 to $300 more than you would pay for antacids or an H2 blocker. A low-dose, over-the-counter PPI such as Prilosec OTC or store-brand or generic version, costs less than the prescription options, but still runs about $10 more a month than the other heartburn drugs.

When should you consider a PPI?

Talk with a doctor if you have heartburn at least twice a week for several weeks, if you often regurgitate food into your throat, or if your heartburn is not relieved by lifestyle changes and antacids or H2 blockers. When a PPI is necessary, start with a low dose of omeprazole or Prilosec OTC (15 mg) or Prevacid 24HR (15 mg). If symptoms improve, consider taking a break after a few weeks. To reduce the risk of rebound heartburn, gradually lower your dose, try taking it every other day, or take an antacid.

Consumer Reports’ Advice

Ease Heartburn without Drugs

Many people with heartburn don’t need drugs at all. They can get all the relief they need from dietary and lifestyle changes.
Watch what (and how) you eat.
Monitor what you eat to figure out which foods and beverages trigger your heartburn. Then try to avoid them. Common triggers include alcohol, oranges and other citrus fruits, chocolate, coffee and other caffeinated beverages, fried foods, garlic and onions, spicy foods, peppermint, and foods rich in tomatoes, such as marinara sauce, salsa, and pizza. It can also help to eat smaller meals and to avoid lying down for at least two hours after eating.
Stop smoking and lose excess weight.
If you need another reason to kick the habit and shed some pounds, heartburn may be it. Smoking and being overweight are clearly linked to heart- burn and gastroesophageal reflux disease (GERD).
Loosen up.
Avoid tight clothes or tight belts that press on your abdomen, because the extra pressure can worsen heartburn symptoms.
Get a good night’s sleep.
To help reduce nighttime flare-ups, try placing wooden blocks under your bedposts to raise the head of your bed about 6 to 8 inches.

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Have you used a PPI for heartburn? What was your experience? What else gives you heartburn relief? Share your thoughts and tips in the comment section below.